Treatment of childhood anxiety disorder in the context of maternal anxiety disorder: a randomised controlled trial and economic analysis

Abstract

BackgroundCognitive–behavioural therapy (CBT) for childhood anxiety disorders is associated with modest outcomes in the context of parental anxiety disorder.ObjectivesThis study evaluated whether or not the outcome of CBT for children with anxiety disorders in the context of maternal anxiety disorders is improved by the addition of (i) treatment of maternal anxiety disorders, or (ii) treatment focused on maternal responses. The incremental cost-effectiveness of the additional treatments was also evaluated.DesignParticipants were randomised to receive (i) child cognitive–behavioural therapy (CCBT); (ii) CCBT with CBT to target maternal anxiety disorders [CCBT + maternal cognitive–behavioural therapy (MCBT)]; or (iii) CCBT with an intervention to target mother–child interactions (MCIs) (CCBT + MCI).SettingA NHS university clinic in Berkshire, UK.ParticipantsTwo hundred and eleven children with a primary anxiety disorder, whose mothers also had an anxiety disorder.InterventionsAll families received eight sessions of individual CCBT. Mothers in the CCBT + MCBT arm also received eight sessions of CBT targeting their own anxiety disorders. Mothers in the MCI arm received 10 sessions targeting maternal parenting cognitions and behaviours. Non-specific interventions were delivered to balance groups for therapist contact.Main outcome measuresPrimary clinical outcomes were the child’s primary anxiety disorder status and degree of improvement at the end of treatment. Follow-up assessments were conducted at 6 and 12 months. Outcomes in the economic analyses were identified and measured using estimated quality-adjusted life-years (QALYs). QALYS were combined with treatment, health and social care costs and presented within an incremental cost–utility analysis framework with associated uncertainty.ResultsMCBT was associated with significant short-term improvement in maternal anxiety; however, after children had received CCBT, group differences were no longer apparent. CCBT + MCI was associated with a reduction in maternal overinvolvement and more confident expectations of the child. However, neither CCBT + MCBT nor CCBT + MCI conferred a significant post-treatment benefit over CCBT in terms of child anxiety disorder diagnoses [adjusted risk ratio (RR) 1.18, 95% confidence interval (CI) 0.87 to 1.62,p = 0.29; adjusted RR CCBT + MCI vs. control: adjusted RR 1.22, 95% CI 0.90 to 1.67,p = 0.20, respectively] or global improvement ratings (adjusted RR 1.25, 95% CI 1.00 to 1.59,p = 0.05; adjusted RR 1.20, 95% CI 0.95 to 1.53,p = 0.13). CCBT + MCI outperformed CCBT on some secondary outcome measures. Furthermore, primary economic analyses suggested that, at commonly accepted thresholds of cost-effectiveness, the probability that CCBT + MCI will be cost-effective in comparison with CCBT (plus non-specific interventions) is about 75%.ConclusionsGood outcomes were achieved for children and their mothers across treatment conditions. There was no evidence of a benefit to child outcome of supplementing CCBT with either intervention focusing on maternal anxiety disorder or maternal cognitions and behaviours. However, supplementing CCBT with treatment that targeted maternal cognitions and behaviours represented a cost-effective use of resources, although the high percentage of missing data on some economic variables is a shortcoming. Future work should consider whether or not effects of the adjunct interventions are enhanced in particular contexts. The economic findings highlight the utility of considering the use of a broad range of services when evaluating interventions with this client group.Trial registrationCurrent Controlled Trials ISRCTN19762288.FundingThis trial was funded by the Medical Research Council (MRC) and Berkshire Healthcare Foundation Trust and managed by the National Institute for Health Research (NIHR) on behalf of the MRC–NIHR partnership (09/800/17) and will be published in full inHealth Technology Assessment; Vol. 19, No. 38.

Recent developments in the treatment of anxiety disorders in children and adolescents

“…This is of potential importance, given the high degree to which anxiety disorders run in families 20. However, in a recent trial of 210 families in which the child (aged 7–12 years) and their mother met diagnostic criteria for a current anxiety disorder, we found relatively good outcomes (with 60–75% recovered by the 12-month follow-up) for children following CBT regardless of the nature of parental support (which included treatment of the mother's anxiety disorder, an intervention focused on mother–child interactions, or active control conditions) 21. Of particular note, improvements in maternal mental health were found across all treatment conditions, highlighting the reciprocal nature of child and parental anxiety.…”

Identifying children with anxiety disorders using brief versions of the Spence Children’s Anxiety Scale for children, parents, and teachers.

“…The trials were approved by Berkshire Research Ethics Committee (reference: 07/H0505/157 and 07/H0505/156) and the University of Reading Research Ethics Committee. All 338 children were referrals to the Berkshire Child Anxiety Clinic, and 175 participated in an RCT comparing child cognitive– behavioral therapy (CCBT) alone, with CCBT supplemented by either cognitive– behavioral therapy (CBT) to target maternal anxiety or an intervention to target mother– child interactions ( Creswell et al, 2015 ); and 163 participated in an RCT comparing two guided parent delivered CBT groups with a wait-list control ( Thirlwall et al, 2013 ). Full details of the recruitment procedure for these trials are reported elsewhere ( Creswell et al, 2015 ; Thirlwall et al, 2013 ), and children were aged 7–11 years at the time of the pretreatment assessment.…”

Review: Prevention of anxiety among at‐risk children and adolescents – a systematic review and meta‐analysis

“…Furthermore, a significant minority of those that do access treatments either terminate treatment prematurely or do not benefit (James et al., ). Intervening to prevent the emergence of anxiety problems among children and young people at risk of their development brings potential advantages from intervening before patterns of responding (among the child and those around them) become ingrained and more difficult to reverse (Donovan & Spence, ), and by reducing the burden on families and services by minimizing the distress and costs associated with childhood anxiety disorders, including missed days at school, lost parent productivity and a broad range of other health and social care costs (Creswell, Cruddace et al., ).…”